Case Study - Page 3

Working with extreme forms of dissociation is a demanding and often anxiety-provoking therapeutic challenge. In the face of extreme symptoms that can seem quite bizarre, the therapist must have the experience, skill, and emotional steadiness to communicate both a clear sense of direction and a conviction about what needs to be done. In the morning-after crisis interview with Trina, Joyanna Silberg displays all those qualities as she creates the kind of emotional bond and sense of safety that enables Trina to return to adequate coping. I question, however, whether the same qualities might have been more patiently employed the night before to help Trina avoid her trip to the emergency room.

In crisis moments, seemingly small shifts in language and affect can have major impact. I was struck by the difference in Silberg’s intervention the night of Trina’s dissociative shutdown and her more effective response in the next day’s follow-up session. In the first instance, Silberg describes her response in this way: “In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life.” The following day, Silberg is far more concrete and makes better use of her strong therapeutic alliance with Trina, as clearly conveyed in her instruction, “Breathe with me. We’ll get through this together.” I can’t help but wonder if the ER trip the previous night could have been avoided if Trina had heard something as powerfully reassuring as, “Breathe with me” and “We’ll get through this together.”

In the session the following morning, Silberg, with conviction and evident affect, simply and unequivocally says to Trina, “You aren’t trapped.” It’s then that Trina is empowered to remember the conversation with her father that had triggered her dramatic shutdown. Silberg reinforces her forceful statement with some powerful suggestions, including: “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.”

I was puzzled by Silberg’s response to Trina’s call from the ER. She describes Trina’s request to help her avoid hospitalization as an example of a “client ask[ing] me for something.” Silberg explains that in such situations she “find[s] a way to ask [child clients] to do something in return that will be a therapeutic advance for them.” This leads her to ask Trina to come for a session the following morning and identify the exact moment that triggered her “dissociative shutdown.” I didn’t understand the rationale that identifying the exact trigger moment would determine whether or not psychiatric hospitalization was needed. If the therapist is asking the client to come to her office the next day to pinpoint the exact moment of being triggered, surely she believes her patient is capable of outpatient therapy. If the client was unable to identify the exact trigger moment in that session, would that really be an adequate justification of psychiatric hospitalization?

Fortunately, the follow-up session is quite productive, reflecting the skills and strengths of both therapist and client. Ultimately, I think the validation of Silberg’s work with Trina and the quality that’s needed to help clients experiencing extreme symptoms like hers is embedded in the adult Trina’s retrospective comment on what her therapy experience meant to her: “Yes, I was a weird kid, but you knew what to do about it.” Clearly Silberg created the sense of safety, trust, and optimism that made it possible for Trina to move on with her life, despite her early abuse.

Author’s Response

I appreciate David Crenshaw’s thoughtful comments. Perhaps I described too quickly the efforts her mother and I made to awaken her the evening before. It was about 45 minutes of intense intervention before her mother and I made the decision to call the medics.

In most outpatient offices, I’d guess, therapists wouldn’t even be able to devote that much time in such an emergency. While it’s certainly possible that I might have hit on the right thing to say if I’d worked on it even longer, my focus at that time was arousing her so that she could safely leave my office, as the behavior occurred at the end of the session. This goal—to have her leave my office—probably came through in my tone and interventions, despite the reassurances that I tried to offer. I was mystified about the exact source of the shutdown, and reassurance alone wasn’t effective. Perhaps unconsciously, Trina was saying that her only safety was in my office, and she couldn’t “leave,” grow up, or achieve adulthood. Thus, my own goal to have her leave my office was incompatible with her goals.

Episodes of unpredictable shutdown, sometimes seen as psychogenic seizures, are sufficient for hospitalization since they can be dangerous. Young people in this state can fall down and hit their heads or not be responsive to the outside world for hours at a time. The question of whether Trina was a treatable inpatient or outpatient was debatable, in that the doctor in the ER thought she was eligible for admission the night before, having witnessed the shutdown state. Had she not been able to use the episode to gain further self-knowledge and increase control, the episode could have been classified as “unpredictable,” and an argument made that this behavior was too dangerous for her to be treated as an outpatient. Realistically, however, had she not been able to get to the bottom of this episode the next day, but seemed to be trying, I most likely would have made another “deal” with her to keep her out of the hospital.